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09/06/2012 14:49 209473 9 BUSNINESSOFFI PAGE 03/06 <br /> Registration for Medical Waste <br /> For Generators of Medical Waste <br /> GENERATOR NAME: 1 s- g <br /> Generator)Facility Address: <br /> City State Zip Code <br /> Phone Number: ( Gl 4 7 3- <br /> Generator Mailing Address: <br /> city State ,Zip Code <br /> Type of Business: <br /> Authorized Representative: _ tAA=2 17'r4�= <br /> Title: <br /> Emergency Phone Number: 4-7 3-- <br /> REGISTRATION FOR: <br /> a.e. Small Quantity Generator with Onsite Treatment(Generates less than 200 lbs/month). <br /> fo Large Quantity Generator Only(Generates 200 lbs or more/month). <br /> ❑ Large Quantity Generator with Onsite Treatment(Generates 200 lbs or more/month). <br /> I declare under penalty of law that to the best of my knowledge and belief the statements made herein <br /> are correct and true. I hereby consent to all necessary inspections made pursuant to the California <br /> Medical Waste Management Act and incidental to the issuance of this registration and the operation <br /> of this business. <br /> Signature: <br /> Title: Date: <br /> 4 <br /> Received Time Sep, 6. 2012 2: 45PM No- 0247 <br />